Case 10: Plication of rectus diastasis 2 years after twin-birth

Theresia Skytte Eriksen; Helle Sjøstrand and Ida Felbo Pold

Journal of Plastic, Breast & Reconstructive Surgery·Relatos de casos cirúrgicos revistos por pares, de acesso abertoRevisto por pares · Acesso aberto

Case 10: Plication of rectus diastasis 2 years after twin-birth · JPBRS

Relato de caso

Case 10: Plication of rectus diastasis 2 years after twin-birth

Theresia Skytte Eriksen¹, Helle Sjøstrand and Ida Felbo Pold¹

¹Department of Plastic Surgery, Herlev and Gentofte Hospital, Denmark

Publicado 2 de abril de 2025204 visualizações6 min de leitura

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Resumo

38-year-old woman underwent plication of symptomatic diastasis of the rectus abdominal muscles after twin-birth by caesarean section. The diastasis had a maximal width of 6,6 cm just above the umbilicus and her symptoms included core-instability, back-pain, and a feeling of being unprotected around her abdomen especially while handling her children. Patient medical history 38-year-old woman had after twin-birth developed symptomatic diastasis of the rectus abdominal muscles. She had no comorbidities. She had an older child of 6 years, and the twins were 2 years old. All children were delivered by uncomplicated caesarean section. The patient described symptoms as back-pain, nausea, core instability, discomfort during running, and pain when encountering pressure to the abdomen especially while handling the children. Physical rehabilitation with physiotherapists had not been successful and hard to complete do to discomfort and pain. Before and After Patient examination The patient was initially examined 15 months postpartum and at an additionally examination two years postpartum by the same surgeon. A preoperative CT-scan at 15 months postpartum, showed a rectus diastasis with the maximal width of 6,6 cm just above the umbilicus. The objective examination confirmed those findings, and a small umbillical hernia was detected. No change in symptoms and width of the diastasis was found between the two examinations. Pre-operative considerations Physical training alone has not been found to reduce the width of the diastasis [1]. Surgery was in one randomized controlled trial superior to physical training with regard to reduction of pain and increase abdominal muscle strength [2]. The swedish guidelines currently recommend that surgery is indic

Pontos-chave de aprendizagem

Dicas

• Surgery eliminates the diastasis not possible by physical exercise alone.

• Surgery reduces symptoms related to the diastasis and appears to have low risk of complications and relapse as well as having a high patient satisfaction rate[4].

• Plication of rectus diastasis is also possible laparoscopic and is perform by gastrointestinal surgeons often in relation to a hernia repair. Extensive loose skin will not be addressed, and the cosmetic result will therefore be hampered by this.

Armadilhas

• The first 8 weeks after surgery the patient must be careful about physical activities and not to strain the abdominal muscles which can be a challenge with smaller children.

• Surgery entails potential complications as bleeding, infection, scarring, sensory disturbances, tissue necrosis, lift of pubic hair, and asymmetric cosmetic result do to loose skin.

Patient history

38-year-old woman had after twin-birth developed symptomatic diastasis of the rectus abdominal muscles. She had no comorbidities. She had an older child of 6 years, and the twins were 2 years old. All children were delivered by uncomplicated caesarean section. The patient described symptoms as back-pain, nausea, core instability, discomfort during running, and pain when encountering pressure to the abdomen especially while handling the children. Physical rehabilitation with physiotherapists had not been successful and hard to complete do to discomfort and pain.

Examination

The patient was initially examined 15 months postpartum and at an additionally examination two years postpartum by the same surgeon.
A preoperative CT-scan at 15 months postpartum, showed a rectus diastasis with the maximal width of 6,6 cm just above the umbilicus. The objective examination confirmed those findings, and a small umbillical hernia was detected. No change in symptoms and width of the diastasis was found between the two examinations.

Pre-operative considerations

Physical training alone has not been found to reduce the width of the diastasis [1]. Surgery was in one randomized controlled trial superior to physical training with regard to reduction of pain and increase abdominal muscle strength [2]. The swedish guidelines currently recommend that surgery is indicated if the diastasis is greater than 5 cm and symptomatic. In case of severe symptoms, a diastasis as low as 3 cm can indicate the need for surgery [3]. With that in mind a surgical plication of the diastasis was considered to be the optimal treatment for this patient.
The patient was informed of the possible complications related to surgery as bleeding, infection, scarring, sensory disturbances, tissue necrosis, placement of suction drain, lift of pubic hair, and asymmetric cosmetic result because of loose skin.
Furthermore, the patient must not have a wish for future pregnancy, and it is recommended that at least 2 years has passed since the latest pregnancy, in order to comply with post-op restrictions.

Passo 1 — Perioperative drawing of the loose abdominal skin before incision

The perioperative drawings are made in a standing position estimating the amount of loose skin expected to be excised.

Passo 2 — Incision and undermining of the abdominal skin

Referências

[1] S. B. Gluppe, M. Ellström Engh, and K. Bø, “Curl-up exercises improve abdominal muscle strength without worsening inter-recti distance in women with diastasis recti abdominis post-partum: a randomised controlled trial,” J Physiother, vol. 69, no. 3, pp. 160–167, Jul. 2023, doi: 10.1016/j.jphys.2023.05.017.
[2] P. Emanuelsson, U. Gunnarsson, U. Dahlstrand, K. Strigård, and B. Stark, “Operative cor-rection of abdominal rectus diastasis (ARD) reduces pain and improves abdominal wall mus-cle strength: A randomized, prospective trial comparing retromuscular mesh repair to double-row, self-retaining sutures,” Surgery (United States), vol. 160, no. 5, pp. 1367–1375, Nov. 2016, doi: 10.1016/j.surg.2016.05.035.
[3] A. Carlstedt et al., “Management of diastasis of the rectus abdominis muscles: recommenda-tions for swedish national guidelines,” Sep. 01, 2021, SAGE Publications Inc. doi: 10.1177/1457496920961000.
[4] G. G. Nervil et al., “Simple plication alleviates physical symptoms in patients with post-gestational rectus diastasis,” Hernia, vol. 27, no. 4, pp. 957–968, Aug. 2023, doi: 10.1007/s10029-023-02814-y.

Post-operative plan

Early mobilization started few hours after surgery. The patient was instructed to turn to the side before getting up from supine position and advised to minimize strain on the abdominal muscles 8 weeks post-operatively, including supporting the abdomen with the hand when coughing and sneezing. The first 4 weeks the patient was advised to sleep on the back with the head slightly elevated. After 8 weeks, rehabilitation with a physiotherapist will begin with a slow progression until full restriction-free movement after 6 months.

For pain management paracetamol and ibuprofen was given and morfin was provided if needed. The pain regulating catheter was discontinued before discharge.

Tranexamic acid was continued for 24 hours: 1g, 4 times à day.

An abdominal elastic belt was provided to use for two months postoperatively, but after the first month only during daytime.

The suction drain was removed when the production was under 30-50 ml à day.

Two weeks postoperatively the patient was seen for suture removal around the umbilicus. Three months postoperatively the patient has a scheduled follow-up appointment with the surgeon.

Pearls

• Surgery eliminates the diastasis not possible by physical exercise alone.

• Surgery reduces symptoms related to the diastasis and appears to have low risk of complications and relapse as well as having a high patient satisfaction rate[4].

Pitfalls

• The first 8 weeks after surgery the patient must be careful about physical activities and not to strain the abdominal muscles which can be a challenge with smaller children.

• Surgery entails potential complications as bleeding, infection, scarring, sensory disturbances, tissue necrosis, lift of pubic hair, and asymmetric cosmetic result do to loose skin.

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Case 10: Plication of rectus diastasis 2 years after twin-birth

Resumo

Pontos-chave de aprendizagem

Patient history

Examination

Pre-operative considerations

Passo 1 — Perioperative drawing of the loose abdominal skin before incision

Passo 2 — Incision and undermining of the abdominal skin

Referências

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Passo 3 — Perioperative drawing and measurement of the diastasis of the rectus abdominal muscles

Passo 4 — Plication of the rectus diastasis and around the umbilicus (Illustration)

Passo 5 — Removal of the extensive loose skin to tighten up the abdomen

Passo 6 — Closure of the incision and re-placement of the umbilicus

Passo 7 — 2 weeks post-op.

Post-operative plan

Pearls

Pitfalls